Forum - Questions & Answers
RN/MA documenting Exam/MDM
I am aware the documentation guidelines state that the ancillary staff is allowed to document the ROS and PFSH sections and my MAC has made it clear that the physician is required to document the HPI. However, are there any guidelines or other documentation that specifically states who can or cannot document the Exam and MDM sections? Is there anywhere that states an RN or MA cannot document the Exam and/or MDM if the physician is signing off on the note?
Thanks.
Rn
because they are not qualified providers.
http://www.trailblazerhealth.com/Publications/Meeting%20Minutes/E-MWBTQA09-30-09.pdf
RN/MA documenting Exam/MDM
Thank you, the link is very helpful to have as documented proof.
but remember
there is a difference between performing and recording. Some physicians employ scribes to document the questions and answers and record their physical exam findings- this is allowed.